Reclassification and risk stratification of embolic stroke of undetermined source by ASCOD phenotyping

Int J Stroke. 2023 Mar;18(3):322-330. doi: 10.1177/17474930221096953. Epub 2022 May 11.


Background: Common vascular diseases underlying stroke, including atherosclerosis, small-vessel disease (SVD), and cardioembolic pathology, can be present in patients with embolic stroke of undetermined source (ESUS), although these are not direct causes of stroke.

Aims: To describe the frequency and degree of the three major diseases using atherosclerosis, SVD, cardiac pathology, other causes, and dissection (ASCOD) phenotyping and to assess their prognostic implications in ESUS.

Methods: In this prospective observational study, 221 patients with ESUS within 1 week of onset were consecutively enrolled and followed up for 1 year. Vascular diseases associated with stroke were assessed using the ASCOD classification. The primary outcome was a composite of nonfatal stroke, nonfatal acute coronary syndrome, and vascular death.

Results: Among 221 patients (mean age, 69.6 years; male, 59.7%), 135 (61.1%), 102 (46.2%), and 107 (48.4%) had any grade of atherosclerosis (A2 or A3), SVD (S3), and cardiac pathology (C2 or C3), respectively. ESUS patients graded as A2 or A3 (i.e. ipsilateral atherosclerotic plaque, contralateral ⩾ 50% stenosis, or aortic arch plaque) were at a significantly higher risk of composite vascular events than those graded as A0 (i.e. no atherosclerotic disease) (adjusted hazard ratio (95% confidence interval), 2.40 (1.01-5.72). No differences were observed in the event risk between patients with S3 (i.e. magnetic resonance imaging evidence of SVD) and S0 (i.e. no SVD) and between those with C2 or C3 (i.e. presence of any cardiac pathology) and C0 (i.e. no cardiac abnormalities).

Conclusions: Atherosclerotic diseases corresponding to ASCOD grade A2 or A3 were predictive of recurrent vascular events in ESUS patients. Reclassification of ESUS using ASCOD phenotyping provides important clues for risk prediction and may guide optimal management strategies.

Keywords: ASCOD; atherosclerosis; cardioembolism; embolic stroke of undetermined source; etiology; small vessel disease.

Publication types

  • Observational Study

MeSH terms

  • Aged
  • Atherosclerosis* / complications
  • Atherosclerosis* / epidemiology
  • Embolic Stroke* / complications
  • Humans
  • Intracranial Embolism* / complications
  • Intracranial Embolism* / epidemiology
  • Male
  • Plaque, Atherosclerotic* / complications
  • Plaque, Atherosclerotic* / diagnostic imaging
  • Plaque, Atherosclerotic* / epidemiology
  • Risk Assessment
  • Risk Factors
  • Stroke* / epidemiology
  • Stroke* / etiology